There’s No Playbook for Treating Gunshot Wounds in Babies

Doctors in Afghanistan are scrambling to address the country’s wave of infant war injuries.

Rafiullah Sharifi was sitting outside the Dasht-e-Barchi Hospital in Kabul, Afghanistan, on the morning of May 12, when three gunmen stormed the building. The 26-year-old was in his car, just outside the hospital gates, when the first explosion happened. He ducked to avoid being hit with bullets and shrapnel and called his wife, Nazia, 24, who had given birth in that hospital just a couple of hours earlier. Sharifi asked his spouse to hide herself and their baby. He stayed on the phone until it disconnected—and then waited for hours while the attack continued and security forces evacuated the babies.

Afterward, Sharifi was allowed inside. Twenty-five people had been killed, including children, mothers, and hospital staff. The interior was still marked with blood and the bodies of the victims. “I found my wife’s body under her bed,” Sharifi told Undark. When Nazia was discovered, her arms were folded in a way that seemed like she had been holding her baby when she died.

The baby had already been rescued and evacuated. She had been shot in the leg several times and was rushed to a different hospital, the French Medical Institute for Mothers and Children. Like many of the 20-plus babies rescued that day, the girl hadn’t even been named yet. Her only identification was a small piece of pink tape on her wrist that read Rafiullah and Nazia’s baby. She had three huge gunshot wounds, said Najeebullah Bina, the pediatric surgeon now overseeing the infant’s care. Her leg was cold and wasn’t getting enough blood. Parts of her muscle and skin had been destroyed. An X-ray revealed that the girl’s leg bones had suffered multiple fractures.

To date, no group has claimed responsibility—but the attack on a maternity ward punctuates a new chapter in the ongoing conflict in Afghanistan, with insurgent groups like the Taliban and ISIS targeting Afghan civilians with increasing frequency. More than 3,000 child casualties were documented in 2019, according to figures from the United Nations, and more than 400 children were killed or injured in the first three months of 2020. This means that pediatric surgeons now face a perverse challenge: determining the best ways to treat toddlers and newborns for war wounds.

“In other countries, people are not shooting on eight- or 11-hour-old babies,” explained Bina. With a lack of specific medical literature to fall back on, he and his colleagues face a host of unknowns when performing complex surgeries on infants.

After examining Sharifi’s daughter, the medical team discussed their relevant clinical experiences, working collectively to piece together a plan that they believed would give her the best chance at surviving. The first step was preventing her condition from deteriorating. The medical team cleaned the baby’s leg wounds and applied topical ointments and bandages. When the girl appeared stable the next morning, the team decided she was ready for a more intense surgical procedure. “We worked nearly four hours on the baby’s leg,” said Bina, “and I am pleased to say we had immediate excellent results.”

Children with such severe war injuries face a difficult future, though. Sharifi’s daughter will need regular checkups to ensure her wounds heal properly, and she may need additional surgeries. For now, the baby’s team is encouraged by small signs of progress: She has gained nearly half a pound since the surgery, and her arteries and veins have healed. “There are little injuries on the sciatic nerves, but she is a baby,” said Bina. “And babies are miracles.”

Still, operating on tiny bodies poses unique challenges. “Surgery on infants up to two years of age requires delicate, fine, and minute attention to details,” said Hamid Stanikzai, a pediatric surgeon from Kabul. As a physician resident in 2015, Stanikzai was working in the emergency room of Indira Gandhi Children’s Hospital in Kabul one night when a truck bomb detonated in the middle of a residential neighborhood.

“We received lots of children that night,” he recalled. One child had been hit in the stomach with shrapnel. Stanikzai performed a laparotomy, creating a large incision in the abdomen for diagnosis and operation. A common procedure in older patients, a laparotomy can be risky when conducted on a baby or young child. According to a trauma manual created by the Royal Children’s Hospital in Melbourne, surgeons must avoid injuring abdominal organs and ribs, which are thinner and more pliable than adults’ and provide less protection.

Jorge Antón, a war surgeon with the Italian-run Emergency Surgical Center for War Victims in Kabul, noted that roughly 30 percent of the patients they receive at their trauma center are children under age 14 and women. “Perhaps the saddest examples are children that step on land mines,” he wrote in an email to Undark. Mines can cause devastating injuries that require amputation.

A 2019 review article published in BMJ Pediatrics Open synthesized data primarily from conflict zones in Afghanistan and the Middle East to better understand blast injuries in children. The authors found that blasts were more damaging and deadly to young children than to older children and adults. The article noted that these patients require more medical care than older victims and that “provisions for this burden are essential.”

Other papers offer glimpses of medical procedures and results in populations of children with war injuries. For example, one paper describes procedures for pediatric blood-vessel injuries, which can be caused by bomb blasts, improvised explosives, and accidents, among other things.  A paper in Journal of Pediatric Surgery describes injuries and treatment outcomes for children admitted to an Israeli medical center during the Syrian civil war. (Among the 117 patients studied, the most common type of injury was head trauma. Nearly 70 percent of the admitted children required surgery, and 97 percent survived.) Another study focused on the first 2,060 pediatric patients treated in U.S.-run military hospitals in Afghanistan and Iraq. The report documented that 75 percent were trauma cases, and over 75 percent of those were penetrative injuries such as gunshot wounds and explosives.

While physicians may consult medical literature for general background, it falls short in providing technical guidance for treating specific war-related injuries, said Bina. For example, he said, there is little evidence about the best way to address complex artery injuries in babies.

Stanikzai concurred. He and his colleagues in Kabul often turn to medical literature for treating other types of trauma—knife wounds, say, or traffic injuries. “But when you are faced with a tragedy like the Dasht-e-Barchi hospital attack,” he said, “we don’t have anything to compare it with.”

Afghanistan’s medical infrastructure is also stretched thin, making it even more difficult to address the physical trauma of ongoing conflict. Like other war-torn, low-income countries, Afghanistan does not have enough specific medical tests, intensive-care units, or primary-care referrals. All of this can delay badly needed medical care and even contribute to unnecessary death. “The most common and at the same time saddest examples,” wrote Antón, involved the many children who were traveling to his hospital from far-off villages but died during the slow journey to get care.

The strain on medical infrastructure is especially acute now that SARS-CoV-2, the virus that causes COVID-19, has spread across the country.

During her recovery in the hospital, Sharifi and Nazia’s baby was given a name: Amina, after the mother of the Prophet Muhammad. Amina was a strong woman, explained Bina, and her name seemed apt “for this little baby who is also strong and such a fighter.” Yet despite her progress, Amina does display evidence of psychological trauma. “She flinches every time someone takes a photo of her,” her father observed. “The sound of the camera clicking seems to scare her. I think that sound reminds her of the bullets.”

“Everyone was praying for her,” said Bina. This baby, he added, “is special and important. Amina has become a symbol of victory in this fragile moment.”